He remains unconscious and lacks capacity to currrently make decisions regarding his further management.

Based on our team’s suspicion of an underlying plasma cell disorder, that may be driving our patient’s hypercalcaemia, AKI and hyperviscosity, a best interests decision is made to urgently investigate.

2% lidocaine and a couple of bone marrow needles later… we obtained a bone marrow aspirate, trephine and samples for flow cytometry and cytogenetics.

Having looked at the aspirate morphology, we felt our suspicions were justified as plasma cells appeared in increased numbers. We even spotted a Dutcher body – immunoglobulin-filled cytoplasm invaginating into the plasma cell nucleus to give the appearance of an intranuclear inclusion.

He has received his first plasma exchange and is planned for daily exchange over the next 48 hours or until his GCS improves.

Our patient improved slightly with intravenous fluid and steroids and has woken up enough to pull out his nasopharyngeal airway! He remains drowsy. He is not able to communicate with us at present.

HDU have inserted a urinary catheter and arterial line to aid our ongoing patient monitoring.

We have prescribed more intravenous saline to balance our patient’s polyuria – which we think may be a symptom of his hypercalcaemia.

We have just heard back from the cytogenetic and flow labs and we now feel confident that our patient does have an underlying plasma cell Myeloma, as we have isolated an aberrant plasma cell population that comprises 25% of the sample.

We established that a haematopathological finding of >10% plasma cells is consistent with a diagnosis of Myeloma.

We are now considering giving an intravenous bisphonate to aid his severe hypercalcaemia but are being cautious given his AKI.